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Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Left MCA syndrome

A

Right hemiparesis (face/arm > leg)
Aphasia
Right sensory/visual inattention
Right hemianopia

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2
Q

Right MCA syndrome

A

Left hemiparesis (arm/face > leg)
Dysarthria
Left sensory/visual inattention
Left hemianopia

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3
Q

Lacunar syndrome

A

Absence of cortical signs
Isolated face/arm/leg weakness or numbness
Dysarthria
Ataxic hemiparesis

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4
Q

Posterior circulation syndrome

A

Diplopia
Dysarthria
Dysphagia
Vertigo
Ataxia
Hemi/tetraparesis
Ipsilateral face/contra lateral body numbness/weakness

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5
Q

Stroke mimics

A

Migraine with aura
Seizure with Todd’s paresis
Functional
Metabolic/Sepsis

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6
Q

CT non con findings

A

Hyperdense area white) = blood or calcium
Hyperdense artery = acute thrombus
Loss of grey/white diff = infarct
Hypodensity (black) = over 4.5hr onset

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7
Q

CT perfusion findings

A

Delay in time to peak = collateral territory (penumbra)

Low cerebral blood volume = likely irreversible ischaemia

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8
Q

CT angio findings

A

Ischaemic stroke
-vessel occlusion or stenosis

ICH
-vascular malformation
-spot sign = marker of growth

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9
Q

MRI brain

A

DWI
-most sensitive

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10
Q

TIA define

A

Same pathophysiology as ischaemic stroke but clot dissolves before causing permanent injury

Now defined as no lesion on MRI DWI
(Not resolution of symptoms within 24hrs)

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11
Q

TIA evaluation and management

A

CT brain
ECG
Carotid imaging
Antiplatletes
Antihypertensives
Statin

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12
Q

Ischaemic stroke aetiology investigations

A

Arterial pathology
CT angio (arch to vertex) or carotid doppler
-atherosclerosis
-dissection
-vasculitis

Cardioembolic pathology
-AF
-Akinetic LV segment
-Endocarditis
-PFO
ECG, holter or telemetry (24hrs) TTE/TOE

Rare (young)
-thrombophilia
-vasculitis
-fabrys

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13
Q

ICH aetiology investigations

A

CT angio
-routine
-vascular malformation

CT venography
-venous sinus thrombosis

Catheter angiography
-subtle AVM or dural AVF

Delayed MRI
-routine at 8 weeks
-underlying mass, AVM, cavernoma
-microangiopathy (hypertensive/amyloid)

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14
Q

Thrombolysis indications

A

Disabling stroke (NIHSS>5) due to large vessel occlusion

<4.5hrs
or
4.5-9hrs post onset or mid point of sleep for CT perfusion selected

Prior to endovascular thrombectomy if thrombolysis indicated

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15
Q

Alteplase administration

A

Dose
0.9mg/kg up to 90mg, infuse over 60 mins with 10% bolus over 1 min

Admit to ICU

CT brain if
-severe headache
-acute hypertension
-nausea or vomiting
-worsening neurological exam

Avoid NGs, IDC, art lines

CT or MRI brain
-24hrs post
-prior to stating antiplatelets/anticoagulants

BP and neurological assessments
-every 15 mins during infusion and for 2hr post
-then every 30 mins for 6hrs
-then hourly until 24 hrs

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16
Q

Thombolysis contraindications

A

Haemorrhage on CT brain
Extensive hypodensity on CT brain
Active non compressible systemic bleeding
Recent GI/GU bleeding, surgery or trauma
BP >185/105
BGL <2.7
IE, aortic dissection, malignant brain tumour
INR > 1.7
Platelets <100
DOAC <48hrs

17
Q

Effect of alteplase 0-3 hrs post onset

A

~1/3rd improve or back to normal
~2/3rd no change
~3% worse, severely disabled or dead

18
Q

Labetalol for emergency reperfusion

A

10-20mg IV over 1-2 mins. Can repeat once

19
Q

Nicardipine for emergency reperfusion

A

5mg/hr IV, titrate up by 2.5mg/hr every 5-15 mins, max 15mg/hr

20
Q

BP targets

A

Thrombolysis
<185/105 pre and for 24hrs post

Ischaemic stroke not for thrombolysis
<220/120

ICH
-around 140 but not substantially below

21
Q

Orolingual angioedema frequency, features, management

A

Frequency
-2% overall
-5% if on ACEi

Features
-unilateral lip and tongue swelling
-contralateral to brain lesion

Maintain airway
-may require intubation
Discontinue alteplase
Cease ACEi
Give methylprednisone 125mg IV
Give diphenhydramine 50mg IV
Give ranitidine 50mg IV
Consider andrenaline 0.3mg sc or 0.5mg neb

22
Q

ICH post thrombolysis frequency and risk factors

A

Haemorrhaging transformation is almost universal
-may be associated with favourable outcome

Haematoma expansion with mass effect beyond infarct is harmful
-rate is 1.7%

Risk factors
-CT hypodensity
-Severe leukoaraiosis
-Large core and severe hypoperfusion
-Delayed reperfusion

23
Q

Symptomatic ICH post thrombolysis management

A

Stop alteplase
CT brain non con
FBC, Coags, fibrinogen, GnH
Give cryo 10u
Give TXA 1g IV
Haematology and neurosurg consult

24
Q

Endovascular thrombectomy indication

A

Ischaemic stroke caused by occlusion of
-ICA
-M1
-Tandem (cervical carotid + intracranial large artery)
-Basilar
-?M2

ICA/M1: <6hr or <24hr with CT perfusion criteria

Basilar time window unclear

Good premorbid function

No age or clinical severity limit

25
Q

Hemicraniectomy indication

A

Under 60
Malignant M1 infarct

26
Q

ICH management

A

Intensive BP lowering
-to around 140 (not substantially below)

Reverse anti coagulation
-warfarin: prothrombinex + vit K
-dabigatran: idarucizumab
-rivaroxaban/apixaban: andexanet alfa
-antiplatelets: NO platelet transfusions

Surgery
-posterior fossa with mass effect
-possibly for supratentorial with mass effect

27
Q

Antiplatelets regime indications

A

DAPT
Indications
-Minor ischaemic stroke (NIHSS <4)
-High risk TIA (ABCD2 >3)
-Not receiving thrombolysis
Timing
-ASAP post CT brain excludes haemorrhage
-Continue for 21 days then mono therapy

Aspirin mono therapy
Indications
-Ischaemic stroke treated with thrombolysis
-Low risk TIA (ABCD2 <4)
Timing
-Post CT brain rules out haemorrhage
-24hrs post thrombolysis

28
Q

Anticoagulation

A

Indicated in AF only

NOAC first line

Warfarin if valvular AF or mechanical heart valve
-valvular = mod-severe MS

Can be commenced post CT brain for TIA

Can be delayed for up to two weeks for ischaemic stroke

Not to be combined with antiplatelet therapy

29
Q

Cholesterol lowering therapy

A

High dose statin for all ischaemic stroke or TIA with possible atherosclerosis contribution

Avoid statin in ICH

Target LDH is <1.8

30
Q

Carotid endarterectomy

A

Strongest indication
-within two weeks (AIS, TIA, retinal ischaemia)
-relevant territory
-stenosis 70-99%

Consider if above and stenosis 50-69%

31
Q

AF detection

A

ECG
Holter or telemetry for at least 24 hours
Longer you look, the more you find

32
Q

Blood pressure lowering secondary prevention

A

Start in all stroke and TIA with BP >140/90

Probably start if BP 120-140

Stroke risk reduction is independent of class
-avoid beta blockers

Ideal long term target not established

33
Q

Stroke/TIA investigations

A

CT brain immediately
-non con
-perfusion
-angio (arch to vertex)

ECG

BGL

Bloods
-FBC, EUC, CMP, CRP
-GnH, coags and fibrinogen if coagulopathic or ICH

Telemetry or holter for > 24 hrs

Repeat CT or MRI brain at 24 hours

TTE

Carotid US if CT angio not done

34
Q

Ischaemic stroke supportive care

A

Admit to stroke unit

Oxygen
-Supplemental only if sats <93%
-On oxygen, aim sats 94-96% (or 88-92%)

Glycemic control
-Aim BGL <10

Fever
-Sepsis screen
-Paracetamol

DVT prophylaxis
-SCUDs for all (no TEDs)

Head position
-doesn’t matter

NBM
-until swallow assessed

35
Q

NIHSS components

A

Level of consciousness
-Alert
-Minor stimulation
-Repetitive stimulation
-Movements to pain
-Postures or unresponsive

Month and age
-Both right
-One right
-Neither right
-Dysarthric, trauma, language barrier, intubated
-Aphasic

Language and aphasia
-Normal
-Some obvious changes with significant limitation
-Fragmentary speech, inferences needed, cannot identify objects
-Mute, coma, no usable speech or comprehension

Dysarthria
-Normal, intubated, unable to test
-Slurring, can be understood
-Unintelligible speech, mute

Blink eyes and squeeze hands
-Both tasks
-One task
-Neither task

Horizontal eye movements
-Normal
-Partial gaze palsy or can be overcome with occulocephalic reflex
-Fixed gaze deviation

Visual fields
-Normal
-Partial hemianopia
-Complete hemianopia
-Bilateral hemianopia or blind

Facial palsy
-Normal symmetry
-Flat nasolabial fold, smile asymmetry
-Lower face unilateral weakness
-Unilateral or bilateral upper and lower weakness

Limb drift
-No drift for 10 seconds, amputation, joint fusion
-Drift, doesn’t hit bed
-Drift, hits bed
-Effort against gravity
-No effort against gravity
-No movement

Finger nose and heel shin
-No ataxia, doesn’t understand, amputation, joint fusion
-Ataxia in one limb
-Ataxia in two limbs

Sensation
-Normal
-Less sharp, more dull
-Compete loss, no response, coma

Inattention
-None
-Sensory, auditory or visual inattention
-Inattention to >1 modality or profound (doesn’t recognise own hand)

Neurology (7 decks)

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